NATIONAL SCIENCE FOUNDATION
APPLICANT SURVEY
Vacancy Ann. #: Position Title/Series/Grade: Position Status (temporary/permanent):
OMB No. 3145-0096 Expiration: 06/2011
INSTRUCTIONS Your completion of this form will be appreciated. Submission of this Information is voluntary and it will have no effect on the processing of your application. The data collected will be used only for statistical purposes to ensure that agency personnel practices meet the requirements of Federal law. Pursuant to 5 CFR 1320.5(b), an agency may not conduct or sponsor, and a person is not required to respond to an information collection unless it displays a valid OMB control number. The OMB control number for this collection is 3145-0096. NSF estimates that each respondent should take about 3 minutes to complete this survey, including time to read the instructions. You may have comments regarding this burden estimate or any other aspect of this survey, including suggestions for reducing this burden. If so, please send them to NSF Reports Clearance Officer, Division of Administrative Services, NSF, 4201 Wilson Blvd., Arlington, VA. 22230. PRIVACY ACT INFORMATION GENERAL - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals completing Federal records and forms that solicit personal information. AUTHORITY - Section 7201 of title 5 of the U.S. Code and Section 2000e-16 of title 42 of the U.S. Code. PURPOSE AND ROUTINE USES The information is used for research and for a Federal Equal Opportunity Recruitment Program (FEORP) to help insure that agency personnel practices meet the requirements of Federal law. Address questions concerning this form and its uses to the Privacy Act Officer, National Science Foundation, Arlington, VA 22230.
1. Today's Date:
2. Year of Birth:
3. How did you learn about the particular position for which you are applying? (Check the appropriate box.) 01 Newspaper (specify) 10 - Federal, State or local job information center 02 Contact with NSF Personnel Office 11 - State vocational rehabilitation agency or (Agency Bulletin Board or other Announcement) Veterans Administration 03 NSF-initiated personal contact 12 - State employment office 04 - Science Magazine, or other professional journal or magazine 13 - School or college counselor or other official (specify) 14 - Private job Information service 05 - Affirmative Action Register 15 - Private employment service 06 - Attendance at conference, meeting or job fair 16 - Friend or relative working at NSF (specify) 17 - Friend or relative not working at NSF 07 - NSF recruitment at school or college 18 – NSF website 08 - Colleague referral 19 – Internet or other website 09 - NSF Bulletin 20 - Other (specify)
4. Select the ethnic category with which you most closely identify: A. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. B. Not Hispanic or Latino. 5. Select one or more racial category with which you most closely identify: A. American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. B. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. C. Black or African American. A person having origins in any of the black racial groups of Africa. D. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. E. White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
6. Sex (check the appropriate box.) F - Female M - Male
7. Please provide Information on your disability status by checking the appropriate category below: 1. I do not have a disability; 2. Hearing impairment; 3. Vision impairment; 4. Missing extremities; 5. Partial paralysis; 6. Complete paralysis; 7. Convulsive disorder; 8. Mental retardation; 9. Mental or emotional illness; 10.Severe distortion of limbs and/or spine; 11.I have a disability but it is not listed. ………………………………………………………………………………………………………………………………………… FOR AGENCY USE Agency Code: ________________ __________________ __________________ __________________ AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER NSF Form 1232 (7/2005)